ABDOMINAL WALL, PERITONEUMOMENTUM, MESENETERY & RETROPERITONEUM (1).pdf

A detailed review about all abdominal wall disorders including peritoneum and retroperitoneum.

1. ABDOMINAL WALL
PERITONEUM/OMENTUM/MESENETERY/
RETROPERITONEUM
BY
Prof. Alaa M. Khodeer

2. By the end of this session
•Identify the diseases of the abdominal wall and the umbilicus.
•Identify the anatomy of the peritoneumand explain the clinical
presentation and management of different types of peritonitis.
•Explain the different location and management of each type of
intraperitoneal abscess.
•Identify the different types of peritoneal tumours.
•Recognize the different surgical conditions affecting the omentum
and mesentery.
•Explain the pathological conditions affecting the retroperitoneal
space.

3. I) DISEASES OF THE ABDOMINAL WALL

4. a)Diseases of the umbilicus
❑Umbilical Fistula:
-Faecal fistula (patent vitello-intestinal duct or acquired).
-Urinary fistula (patent urachus or acquired).
-Biliary fistula (perforation of bowel or biliary tree).
❑Umbilical sinus: due to umbilical infection.
❑Umbilical granuloma : granulation tissue from chronic infection.
❑Umbilical polyp: persistence of umbilical end of vitello-intestinal duct with
formation of polypoidal mass.
❑Umbilical stone: due to chronic inflammation or granuloma.
❑Umbilical hernia.
❑Umbilical tumours: primary tumour as squamous cell carcinoma or more
common: metastatic tumour (Sister Mary Joseph nodule).

5. b) Desmoid tumour
•Locally malignant fibrosarcoma/ Hamartoma.
•More common females.
•Arises from rectus sheath (anterior > posterior).
•Can arise on top of scars or incisions.
•Can be associated with intestinal polyposis
(Gardener’s syndrome).
•Painless, ill-defined, slowly growing mass of the abdominal wall
infiltrating the surrounding structures.
•Management: Excision with a safety margin of > 1 inch with skin
coverage.

6. c) Rectus sheath haematoma
•Due to trauma to inferior epigastric vessels or due to coagulopathy.
•Painful swelling over the rectus muscle.
•Management:
-Conservatively / Embolization of the bleeding vessel / Surgical
exploration and ligation of the inferior epigastric vessels.

7. II) DISEASES OF THE PERITONEUM

8. The Peritoneum
-Single layer of mesothelial cells resting on loose connective tissue.
-Can absorb large volume of fluids.
-Divided into:
➢Parietal Peritoneum: lines all the abdominal cavity:
-Sensitive(somatic and visceral innervation)----> Muscle
guarding/reflex spasm.
-Healing occurs by the development of
new mesothelial cells over the defect.
➢Visceral Peritoneum:
covers all the intra-abdominal viscera:
Insensitive(autonomic nervous system).

9. Peritonitis
•Definition:
Inflammation of the peritoneum.
•Causes:
-Infective (Septic): bacterial (GIT/ Urinary tract).
-Chemical : bile, barium.
-Allergic: Starch.
-Traumatic: Surgical/Accidental trauma.
-Ischaemic : strangulated bowel.
-Miscellaneous: Familial Mediterranean fever.

10. 1) Infective (Septic) Peritonitis
•Causative organisms:
-GIT:
E.coli, Streptococci, Enterococci, Bacteroides, Pneumococci, Staphylococci, Klebsiella and
Clostridium.
-Other sources:
Chlamydia, Gonorrhoeae, Staphylococci, Haemolytic streptococci, Staphylococci, Mycobacterium
tuberculosis and fungal infections.
•Causes:
-Infected organs (transmural): e.g. appendicitis , diverticulitis , etc.
-Leaking organs (Direct): e.g. perforated peptic ulcer , urine extravasation, leaking anastomosis,
etc.
-Exogenous: e.g. operative or traumatic wound, drains, etc.
-Blood spread: in septicaemia and pyaemia.
-Primary (Spontaneous) peritonitis : no apparent Intraperitoneal pathology.

11. •Fate:
Depends on the virulence of the organisms:
➢Resolution: Peritoneum has great resistance to infection with
resolution of infection.
➢Localization and abscess formation : Either
-Around the primary focus Or
-Anatomical compartments of the
peritoneal cavity e.g. Subphrenic abscess.
➢Flaring up:
To generalized peritonitis.

12. •Clinical Picture:
➢Localized Peritonitis:
Picture of the original cause: e.g. appendicitis, cholecystitis, diverticulitis, etc.
➢Generalized Peritonitis:
-Pain
-Vomiting
-Abdominal distension
-Absolute constipation
-Patient looks distressed and toxic with Hippocratic facies ( sunken eyes with anxious look).
-Patient lies still in bed avoiding movements.
-Tachycardia and pyrexia.
-Generalized abdominal tenderness , rebound tenderness and rigidity.
-Absent bowel sounds.

13. •Investigations:
➢Laboratory: CBC(Leucocytosis), inflammatory markers (CRP), Lactate,
Urea, Electrolytes, Serum amylase and urine dipstick.
➢ECG
➢Imaging:
-Erect Chest X-Ray: can show air under diaphragm.
-Supine abdominal X-Ray: can show dilated bowel loops.
-U/S Abdomen and pelvis: for right upper quadrant and gynaecological
pathology.
-CT abdomen: investigation of choice for
diagnosis and decision making.

14. •Management:
➢General Management:
-Fluid and electrolytes correction.
-NGT and urinary catheter.
-Antibiotics(Broad spectrum).
-Analgesia.
-ICU if needed.
➢Specific treatment of cause:
-Early surgery is preferred.
-Open / Laparoscopic approach and dealing with the cause e.g.
appendectomy.
-Aspiration of pus with saline irrigation of all quadrants of abdomen.
-Insertion of drains.

15. 2) Spontaneous Bacterial Peritonitis
-Acute bacterial infection of ascitic fluid.
-Rare.
-Affects patients with cirrhosis and ascites.
-Clinical picture of peritonitis + Worsening of liver functions.
-Hepatic encephalopathy and GI bleeding.
-Diagnosed by increase of neutrophils in ascites fluid.
-Treatment by antibiotics.

16. 3) Primary Pneumococcal Peritonitis
•Complicate nephrotic syndrome or cirrhosis in children.
•Usually girls between 3 and 9 years.
•Route of infection is usually vagina and fallopian tubes.
•Picture of abdominal and pelvic peritonitis ( profuse diarrhea and
increased frequency of micturition).
•Management:
-Antibiotics
-Surgery(open / laparoscopic) with peritoneal lavage.

17. 4) Tuberculous Peritonitis
•Common in poor countries.
•Mycobacterium-intracellulare.
•Spread from ileocecal TB.
•Ascites with peritoneal tubercle deposits.
•U/S and CT scan with ascitic aspiration can be diagnostic.
•Systemic anti-tuberculous treatment.
•Surgery may be required if associated with intestinal obstruction.

18. III) INTRAPERITONEAL ABSCESS

19. •It has better outcome than generalized peritonitis.
•Body defensive mechanism (Omentum and matting of bowel loops) has
been successful in localizing the source of infection.
•It is divided according to its location into:
-Right and left subphrenic.
-Right and left subhepatic.
-Right and left iliac.
-Pelvic.

20. •Right subphrenic abscess:
-Between the right lobe of the liver the diaphragm
-Causes: perforated cholecystitis , perforated duodenal ulcer and duodenal stump blow out.
•Left subphrenic abscess:
-Between the diaphragm , the left lobe of the liver and the anterior surface of the stomach.
-Causes: Following surgery on the stomach, tail of pancreas, spleen and splenic flexure of the
colon.
•Right subhepatic abscess:
-Beneath the right lobe of the liver ( Rutherford Morison’s pouch).
-Causes: appendicitis, cholecystitis, perforated duodenal ulcer or upper abdominal surgery.
•Left subhepatic abscess:
-Beneath the left lobe of the liver
-Causes: complicated acute pancreatitis.

21. •Right iliac fossa abscess:
-At the right paracolic gutter.
-Causes: Acute appendicitis or perforated duodenal ulcer, Tubal or ovarian
origin.
•Left iliac fossa abscess:
-At the left paracolic gutter.
-Causes: perforated diverticulitis, perforation of carcinoma of the sigmoid
colon.
•Pelvic abscess:
-In the pelvis.
-Causes: acute appendicitis, pelvic inflammatory disease in females, tubo-
ovarian origin, anastomotic leak after colorectal surgery or resolving
generalized peritonitis.

22. Clinical picture of intraperitoneal abscess
•General :
-Hectic (swinging) fever.
-Tachycardia.
-Toxaemia with anorexia, vomiting, sweating and wasting.
•Local:
-Pain and tenderness at the site of the abscess.
-Impaired chest movement and possible pleural effusion.
-Diarrhea and passage of mucus in the stools in cases of pelvic abscess.

23. Investigations and treatment of Intraperitoneal abscess
•Leucocytosis and raised inflammatory markers.
•Plain chest X-ray:
-Thickened and elevated diaphragm (tented diaphragm)
-Obliteration of costophrenic angle with pleural effusion.
-Air under diaphragm: in cases of perforated viscus.
-U/S.
-CT scanning.
-Management:
Antibiotics coverage
+
➢Ultrasound / CT Guided drainage
➢Open drainage with breaking down of any fibrous septa with insertion of drainage tube (preferably extra-
serous).
➢Rectal or vaginal drainage can be attempted for pelvic abscess.

24. IV) PERITONEAL TUMOURS

25. a) Primary tumours
•Mesothelioma:
-Rare tumour.
-Can affect the pleura.
-Suspected to be caused by exposure to asbestos.
-Either diffusewith ascites or localized.
-Treatment by chemo cytotoxic agent.

26. b) Secondary tumours
1)Carcinomatosis peritonei:
➢Origin:
-Terminal event in cases of carcinoma of the stomach, colon, breast, ovary and
other abdominal organs.
-Caused by implantation of secondaries on the peritoneum.
➢Pathology:
-Th peritoneum (visceral and parietal) is studded with secondary nodules and
blood stained (straw coloured) ascites.
➢Treatment:
-Treatment for underlying malignancy.
-Intraperitoneal chemotherapy.

27. 2) Pseudomyxoma peritonei:
➢Aetiology:
i)Rupture of pseudomucinous cyst of the ovary.
ii)Rupture of a mucocele or mucoid carcinoma of the appendix.
➢Pathology:
The abdomen is filled with yellow jelly-like material (pseudomucin) with fibrous
adhesions.
➢Clinical picture:
-Distended abdomen (no shifting dullness) with multiple palpable firm masses.
➢Diagnosis:
CT scan or during surgery (laparotomy or laparoscopy).
➢Treatment:
-Excision of the jelly-like material.
-Excision of the appendix with any ovarian tumour.
-Intraoperative chemotherapy followed by excision of the peritoneum.

28. V) THE OMENTUM

29. Torsion of the omentum
•Aetiology:
Due to adhesions of the omentum to hernia or an old focus of
infection.
•Clinical picture:
-Sudden abdominal pain.
-Abdomen is rigid and tender.
-Twisted omentum may be palpable.
•Treatment:
Surgical excision of twisted omentum.

30. VI) THE MESENTRY

31. 1) Mesenteric Cyst
➢Definition:
Fluid collection between the 2 layers of mesentery of small bowel.
➢Types: False or true
-False mesenteric cyst:----> Without epithelial lining:
a)Blood cyst: haematoma of mesentery after trauma.
-Treatment by evacuation.
b) Tuberculous mesenteric cold abscess: caseating tuberculous
mesenteric adenitis.
-Treatment by anti-tuberculous drugs.

32. -True mesenteric cyst:-----> With epithelial lining:
a)Chylolymphatic cyst: commonest
-It is a retention cyst due to obstructed lymphatic drainage.
-Thin walled cyst lined with epithelium. Contains lymph.
-Blood supply is sperate from the related loop of intestine.
-Treatment is by enucleationleaving the bowel intact.
b) Enterogenous cyst:
-Arises from sequestered intestinal epithelium or from duplicated
intestine.
-Thick walled lined with intestinal mucosa. Contains mucous.
-Blood supply is derived from the same vessels of the loop of intestine.
-Treatment is by excision with resection of the bowel loop.

33. ➢Clinical Picture of mesenteric cysts:
-Encountered in children and young adults.
-More common in women.
-Painless abdominal swelling.
-Sometimes recurrent abdominal pain or acute abdomenfrom torsion or rupture of the cyst.
-Tillaux Triad:
▪Fluctuant swelling near the umbilicus.
▪Swelling moves freely across but not along the mesentery.
▪The cyst is dull on percussion with zone of resonance around and over it(due to presence of
bowel loops).
➢Management of mesenteric cyst:
▪U/S and CT abdomen show the cyst.
▪Treatment: Either:
-Enucleation of the cyst.
-Excision of the cyst with bowel resection.

34. 2) Mesenteric lymphadenitis
a)Acute non specific , ileocecal mesenteric adenitis:
➢Commonest cause of acute abdominal pain in children.
➢Aetiology:
-Unknown. May be of viral origin following respiratory tract infection.
➢Pathology:
-Ileocecal lymph nodes are discrete, soft and pinkthen become firm and
white.
➢Clinical Picture:
-Upper abdominal pain, colicky in nature, that localizes to the right side of
lower abdomen.
-Nausea, vomiting, malaise, anorexia and fever.

35. -Muscle guarding.
-Abdominal tenderness with rebound tenderness.
-The above picture similar to ACUTE APPENDICITIS.
-Shifting tenderness:
▪Valuable sign to differentiate this condition from acute appendicitis.
▪After laying the patient on the left side for a few minutes the point of
maximum tenderness shifts towards the middle line.
➢Treatment:
-If there is a doubt not ruling out appendicitis its is better to perform
appendectomy or diagnostic laparoscopy.
-Usually the condition settles after bed rest and simple analgesia.

36. b) Tuberculous mesenteric adenitis:
➢Less common. Due to ingestion of contaminated milk
➢Pathology:
-Small focus in the distal ileum (Peyer’s patches).
-Can be with huge enlargement of mesenteric lymph nodes.
➢Presentation:
-Generalized constitutional symptoms with fever, sweating, wasting…etc.
-Abdominal pain with vomiting and diarrhea.
-Palpable tender mass in the lower abdomen with rebound tenderness.
-Abdominal X-ray can show calcified nodes.
-Treatment:
-Anti-tuberculous treatment

37. VII) RETROPERITONEUM

38. ❑Retroperitoneal fibrosis:
-Rare condition.
-Mostlyidiopathic.
-Development of grey/white plaque of tissue that spreads in the
retroperitoneal space to involve the iliac vessels, aorta and ureters.
-Presents with : Chronic backpain , lower limb and scrotal oedema or
ureteric obstruction.
❑Retroperitoneal (psoas) abscess:
-Direct spread from inflamed or perforated digestive or urinary tract.
-Presents with abdominal pain, fever and may be with groin mass.
-Pain with passive extension of hip.
-CT scan is diagnostic
-Treatment : CT guided drainage+ antibiotics cover.

39. ❑Retroperitoneal tumours:
➢Primary tumours arising from retroperitoneal muscles, fat, lymph nodes and nerves.
➢Pathology: Commonest tumours are:
a)Retroperitoneal lipoma:
-More common in women.
-Can reach huge size.
-Can undergo myxomatous changes.
-Usually malignant (liposarcoma).
b) Retroperitoneal sarcoma:
-Liposarcoma, leiomyosarcoma, malignant histiocytoma.
➢Presentation:
-Late presentation. Usually grow very large.
-Non specific abdominal pain and fullness.
-CT and MRI are diagnostic.
➢Treatment:
-Surgical excision with adjacent involved organ.
-Poor prognosis.

40. take home message
•Different surgical conditions can affect the umbilicus.
•Desmoid tumour is locally malignant tumour arising from the rectus sheath.
•Septic peritonitis is serious surgical emergency that needs early detection
and prompt management.
•Intraperitoneal abscess is usually managed by image guided drainage and
antibiotics.
•Mesenteric cysts can by enucleated or excised with or without bowel
resection.
•Retroperitoneal tumours are aggressive tumours with poor prognosis.

41. references
•Bailey and Love’s Short Practice of Surgery 27
th
Edition
•Sabiston Textbook of Surgery 20
th
Edition